Effectiveness of Reprocessing for Flexible Bronchoscopes and Endobronchial Ultrasound Bronchoscopes

Fluid retention in endoscopes: A real-world study on drying effectiveness

BACKGROUND

Outbreaks linked to inadequate endoscope drying have infected numerous patients, and current standards and guidelines recommend at least 10 minutes of forced air for drying channels. This study evaluated a new forced-air drying system (FADS) for endoscopes.

METHODS

Drying was assessed using droplet detection cards; visual inspection of air/water connectors, suction connectors, and distal ends; and borescope examinations of endoscope interiors. Assessments were performed after automated endoscope reprocessor (AER) alcohol flush and air purge cycles and after 10-minute FADS cycles.

RESULTS

Researchers evaluated drying during encounters with 22 gastroscopes and 20 colonoscopes. After default AER alcohol and air purge cycles, 100% (42/42) of endoscopes were still wet. Substantial fluid emerged from distal ends during the first 15 seconds of the FADS cycle, and droplets also emerged from air/water and suction connectors. Following FADS cycle completion, 100% (42/42) were dry, with no retained fluid detected by any of the assessment methods.

CONCLUSIONS

Multiple endoscope ports and channels remained wet after AER cycles intended to aid in drying but were dry after the FADS cycle. This study reinforced the need to evaluate the effectiveness of current drying practices and illustrated the use of practical tools in a real-world setting.

Factors associated with damages and repair costs of reusable flexible bronchoscopes in pediatrics in China

BACKGROUND

Frequent repairs of pediatric flexible bronchoscopes can lead to a huge financial burden for the hospital. This study aimed to investigate the common causes of the failures in pediatric flexible bronchoscopes and propose the measures to prevent the failures.

METHODS

This was a retrospective study. We collected repair information of the pediatric flexible bronchoscopes reprocessed in the Department of Sterile Processing at a hospital between September 1, 2018 and September 1, 2022 in order to investigate the causes and possible factors associated with the failures in pediatric flexible bronchoscopes.

RESULTS

The Department of Sterile Processing staff reprocessed the pediatric flexible bronchoscopes 4280 times. A total of 29 failures were identified. The failure rate was 0.678%. The average repair cost was USD7246.60. The common failures in the pediatric flexible bronchoscopes included dim video image, black dots, improper video image display or no image during angulation adjustment, and pressure marks in the insertion tube. The failure rates in flexible electronic bronchoscopes and small-diameter flexible bronchoscopes were 65.5% and 93.1%, respectively. The failure rate in the pediatric flexible bronchoscopes reprocessed by the staff members with less work experience was 75.9%.

CONCLUSION

The failure rate in the pediatric flexible bronchoscopes was not high but the repair costs were extremely high. The types and size of the flexible bronchoscopes and work experience of the staff members responsible for bronchoscope reprocessing were the possible factors associated with the failure rate in the pediatric flexible bronchoscopes. It is advisable to further optimize the central workflow and management mode for reprocessing the pediatric flexible bronchoscopes, thereby extending their useful life and reducing costs.

Bronchoscopy-related outbreaks and pseudo-outbreaks: A systematic review

OBJECTIVE

To identify and report the pathogens and sources of contamination associated with bronchoscopy-related outbreaks and pseudo-outbreaks.

DESIGN

Systematic review.

SETTING

Inpatient and outpatient outbreaks and pseudo-outbreaks after bronchoscopy.

METHODS

PubMed/Medline databases were searched according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, using the search terms "bronchoscopy," "outbreak," and "pseudo-outbreak" from inception until December 31, 2022. From eligible publications, data were extracted regarding the type of event, pathogen involved, and source of contamination. Pearson correlation was used to identify correlations between variables.

RESULTS

In total, 74 studies describing 23 outbreaks and 52 pseudo-outbreaks were included in this review. The major pathogens identified in these studies were Pseudomonas aeruginosa, Mycobacterium tuberculosis, nontuberculous mycobacteria (NTM), Klebsiella pneumoniae, Serratia marcescens, Stenotrophomonas maltophilia, Legionella pneumophila, and fungi. The primary sources of contamination were the use of contaminated water or contaminated topical anesthetics, dysfunction and contamination of bronchoscopes or automatic endoscope reprocessors, and inadequate disinfection of the bronchoscopes following procedures. Correlations were identified between primary bronchoscope defects and the identification of P. aeruginosa (r = 0.351; P = .002) and K. pneumoniae (r = 0.346; P = .002), and between the presence of a contaminated water source and NTM (r = 0.331; P = .004) or L. pneumophila (r = 0.280; P = .015).

CONCLUSIONS

Continued vigilance in bronchoscopy disinfection practices remains essential because outbreaks and pseudo-outbreaks continue to pose a significant risk to patient care, emphasizing the importance of stringent disinfection and quality control measures.

Beyond Endoscopes: Pilot Study of Surgical Instrument Lumen Inspection

Objective: Borescope examinations of endoscope channels are commonly described in literature, but no studies on surgical instrument lumen inspection have been published recently. Inadequately processed surgical instruments have been implicated in patient infections. This study assessed the utility of borescopes for inspecting surgical instruments. Methods: The study team inspected and photographed sterilized, patient-ready arthroscopic shaver handpieces and suction tips using a tablet camera and borescopes to characterize internal anatomy, defects found in lumens, and the impact of recleaning on debris or residues. Results: Ten suctions and eight shavers were inspected. All suctions had internal ridges and suction holes that were perpendicular to the lumen. All shavers had visible ridges, elbows, and lever mechanisms inside lumens. Of the 18 instruments, 16 (88%) had internal features that appeared rough or jagged and 17 (94%) had visible debris or discoloration in the lumens. Recleaning efforts generally were effective for suctions, but multiple rounds of recleaning with enhanced steps were less effective for shavers, which were replaced. Researchers documented retained soil and brush bristles in several new shavers despite following manufacturer instructions for cleaning and found visible damage and discoloration within five uses. Discussion: This study demonstrated the value of borescope examinations for surgical instrument lumens. Visual inspections identified anatomical features that could influence cleaning effectiveness and detected residual soil, discoloration, and debris in most instruments. The findings suggested that manufacturer cleaning instructions were insufficient and additional cleaning was not always effective. In response, the site's multidisciplinary team strengthened risk assessment protocols and enhanced their cleaning practices.

Environmental Impact of Bronchoscopy: Analysis of Waste Mass and Recyclability of Bronchoscopic Equipment and Consumables

BACKGROUND

Greenhouse gases (GHGs) are significant contributors to climate change, and CO2 equivalent (CO2-e) is measured to compare emissions from GHGs. The healthcare sector contributes 4.4% of global CO2-e emissions, mainly with energy consumption and, in lesser extent, waste production. In this regard, bronchoscopy procedures produce a large amount of waste and are responsible for a significant consumption of energy.

OBJECTIVE

We aimed at quantifying the impact on waste mass production, energy consumption, and recyclability of bronchoscopic procedures.

METHODS

We conducted a prospective single-centre observational study; for each type of procedure (performed with either reusable or single-use instruments), the number of items used, their weight, and recyclability were evaluated, as well as the material of which recyclable waste was made of. We then calculated the total amount of waste produced, its recyclability, energy consumption, and CO2-e produced over 10 days of activity in our Interventional Pulmonology Unit.

RESULTS

Sixty procedures generated 61,928 g of waste, of which only 15.8% was potentially recyclable. Single-use instruments generated nearly twofold more recyclable waste than reusable ones, 80% during the procedure phase. Reusable instruments generated 45% of waste during the reprocessing phase, of which 50% was recyclable. The recyclable material was totally composed of paper and plastic. During 10 days of activity, we consumed 64 kWh and produced more than 67 kg of CO2-e due to non-recyclable waste and energy consumption.

CONCLUSIONS

Our results confirm the compelling need to recycle as many materials as possible, even if the amount of recyclable waste is limited. In this respect, official documents issued by international societies are urgently needed to align our activity with climate requirements and improve the sustainability of our work.

Efficacy of high-level disinfection of endoscopes contaminated with Streptococcus equi subspecies equi with 2 different disinfectants

BACKGROUND

Prevention of spread of Streptococcus equi subspecies equi (S. equi) after an outbreak is best accomplished by endoscopic lavage of the guttural pouch, with samples tested by culture and real time, quantitative polymerase chain reaction (qPCR). Disinfection of endoscopes must eliminate bacteria and DNA to avoid false diagnosis of carrier horses of S. equi.

HYPOTHESIS/OBJECTIVES

Compare failure rates of disinfection of endoscopes contaminated with S. equi using 2 disinfectants (accelerated hydrogen peroxide [AHP] or ortho-phthalaldehyde [OPA]). The null hypothesis was that there would be no difference between the AHP and OPA products (based on culture and qPCR results) after disinfection.

METHODS

Endoscopes contaminated with S. equi were disinfected using AHP, OPA or water (control). Samples were collected before and after disinfection and submitted for detection of S. equi by culture and qPCR. Using a multivariable logistic regression model-adjusted probability, with endoscope and day as controlled variables, the probability of an endoscope being qPCR-positive was determined.

RESULTS

After disinfection, all endoscopes were culture-negative (0%). However, the raw unadjusted qPCR data were positive for 33% AHP, 73% OPA, and 71% control samples. The model-adjusted probability of being qPCR-positive after AHP disinfection was lower (0.31; 95% confidence interval [CI], -0.03-0.64) compared to OPA (0.81; 95% CI, 0.55-1.06), and control (0.72; 95% CI, 0.41-1.04).

CONCLUSION AND CLINICAL IMPORTANCE

Disinfection using the AHP product resulted in significantly lower probability of endoscopes being qPCR-positive compared to the OPA product and control.

Single-use flexible bronchoscopes vs traditional reusable flexible bronchoscopes: a prospective controlled study

BACKGROUND

Single-use flexible bronchoscopes(SFB) eliminate the risk of bronchoscopy-related infection compared with traditional reusable flexible bronchoscopes(RFB). At present, there is no comparative study between SFB and RFB in the aspects of biopsy and interventional therapy. This study aims to explore whether SFB can perform complex bronchoscopic procedures such as transbronchial biopsies just like RFB.

METHODS

We conducted a prospective controlled study. A total of 45 patients who required bronchoscopic biopsy in our hospital from June 2022 to December 2022 were enrolled. The patients were divided into the SFB group and the RFB group, and routine bronchoscopy, bronchoalveolar lavage, and biopsy were performed respectively. Data on the time of routine bronchoscopy, the recovery rate of bronchoalveolar lavage fluid(BALF), biopsy time, and bleeding volume were collected. Then we used the two-sample t-test and the χ² test to assess the performance differences between SFB and RFB. We also designed a questionnaire to compare the performance between SFB and RFB by different bronchoscope operators.

RESULTS

The routine examination time of SFB and RFB was 3.40 ± 0.50 min and 3.55 ± 0.42 min, respectively. There was no significant difference between the two groups (P = 0.308). The recovery rate of BALF was (46.56 ± 8.22) % in the SFB group and (47.00 ± 8.07) in the RFB group, without a significant difference between the two groups(P = 0.863). The biopsy time was similar(4.67 ± 0.51 min VS 4.57 ± 0.45 min) in both groups, with no significant difference(P = 0.512). The positive biopsy rate was 100% in both groups, with no significant difference. Overall, the bronchoscope operators were generally satisfied with SFB.

CONCLUSION

SFBs are non-inferior to RFBs in routine bronchoscopy, bronchoalveolar lavage, and biopsy. It is suggested that SFBs have a wider clinical application.

Systematic Review and Cost-Consequence Analysis of Ambu aScope 5 Broncho Compared with Reusable Flexible Bronchoscopes: Insights from Two US University Hospitals and an Academic Institution

OBJECTIVE

The aim of this study was to perform a systematic review, meta-analysis and cost-consequence analysis of the single-use bronchoscope, Ambu aScope^TM 5 Broncho, in relation to reusable flexible bronchoscopes (RFB) available within three high procedure volume university hospitals and academic institutions in the USA.

METHODS

The primary outcome was incremental cost and the secondary outcome was incremental cross-infection risk of use for both the single-use flexible bronchoscope (SUFB) and RFBs. Cost estimates included capital, repair, and reprocessing costs derived from a prospective observational micro-costing approach within three large university hospitals and academic institutions. All costs were valued in 2022 US dollars (USD). A meta-analysis based on literature covering cross-contamination and infection from 2010 to 2020 investigated cross-infection risk following bronchoscopy procedures with RFBs. Capital costs were discounted at 3% over 5-8 years. All parameters were evaluated using both univariate deterministic and probabilistic sensitivity analyses.

RESULTS

In high-volume hospitals, RFBs were cost minimizing compared to SUFBs. Probabilistic sensitivity analysis showed that RFBs were cost saving in 88% of iterations. Univariate analyses illustrated sensitivity of the base-case result to the procedure volume. Data from sensitivity analyses suggest that the two interventions are cost neutral at a break-even point of 756 procedures per year or 46 procedures per bronchoscope per year.

CONCLUSION

Assuming equivalent clinical performance, single-use flexible bronchoscopes are not cost minimizing when including the costs associated with cross-infection in high-volume US university hospitals and academic institutions. Overall, the benefits of conversion from RFBs to SUFBs are dependent on the annual procedure volume of individual hospitals, expected cross-infection risk, and purchase price of the aScope 5 Broncho.

Cross-contamination rate of reusable flexible bronchoscopes: A systematic literature review and meta-analysis

Background

Bronchoscopy is generally a safe and efficient procedure. However, the risk of cross-contamination with reusable flexible bronchoscopes (RFB) has been detected in several outbreaks worldwide.

Aim

To estimate the average cross-contamination rate of patient-ready RFBs based on available published data.

Methods

We performed a systematic literature review in PubMed and Embase to investigate the cross-contamination rate of RFB. Included studies identified indicator organisms or colony forming units (CFU) levels, and total number of samples >10. The Contamination threshold was defined according to the European Society of Gastrointestinal Endoscopy and European Society of Gastrointestinal Endoscopy Nurse and Associates (ESGE-ESGENA) guidelines. To calculate the total contamination rate, a random effects model was applied. Heterogeneity was analysed via a Q-test and illustrated in a forest plot. Publication bias was analysed via the Egger’s regression test and illustrated in a funnel plot.

Results

Eight studies fulfilled our inclusion criteria. The random effects model included 2169 samples and 149 events (positive tests). The total RFB cross-contamination rate was 8.69% ± 1.86 (standard division [SD]) (95% confidence interval [CI]: 5.06–12.33%). The result showed significant heterogeneity of 90% and publication bias.

Discussion

Significant heterogeneity and publication bias is likely associated with varying methodology and aversion towards publishing negative findings, respectively. Based on the cross-contamination rate an infection control paradigm shift is needed to ensure patient safety. We recommend to follow the Spaulding classification and classify RFBs as critical items. Accordingly, infection control measures such as obligatory surveillance, and implementing single-use alternatives must be considered where feasible.

Single Use or Disposable Flexible Bronchoscopes: Bench Top and Preclinical Comparison of Currently Available Devices

BACKGROUND

Data regarding the risk of infection related to reusable bronchoscopes, the global drive toward disposable technology and the COVID-19 pandemic have led to an increase in the use and production of single use or disposable bronchoscopes. An in-depth comparison of all available devices has not been published.

METHODS

A benchtop comparison of the Ambu^®aScope^TM, Boston Scientific^® EXALT^TM Model B, the Surgical Company Broncoflex^© Vortex, Pentax^® Medical ONE Pulmo™, and Vathin^® H-Steriscope^TM (all 2.8 mm inner dimension other than the Pentax single-use flexible bronchoscope (3 mm)) was undertaken including measurement of maximal flexion and extension angles, thumb force required and suction with and without biopsy forceps. Thereafter, preclinical assessment was performed with data collected including experience, gender, hand size, and scope preference.

RESULTS

The Vathin single-use flexible bronchoscope had the biggest range of tip movement from flexion to extension with and without forceps. The Boston single-use flexible bronchoscope required the maximal thumb force but had the least reduction of tip movement with forceps. The Boston single-use flexible bronchoscope significantly outperformed all other scopes including the standard Pentax scope and was the only scope capable of suctioning pseudo-mucus around the forceps. Although there was no significant difference in preference in the overall group, females and those with smaller hand size preferred the Pentax and males the Broncoflex single-use flexible bronchoscope.

CONCLUSIONS

Currently available single-use flexible bronchoscopes differ in several factors other than scope sizes and monitor including suction, turning envelope, and handle size. Performance in the clinical setting will be key to their success.

The utility of lighted magnification and borescopes for visual inspection of flexible endoscopes

INTRODUCTION

Infections have been linked to damaged or contaminated endoscopes with visible defects. Endoscope processing standards and guidelines state endoscopes should be visually inspected every time they are used. This study evaluated a new visual inspection program using magnification and borescopes in an endoscopy department that had not previously utilized these tools.

METHODS

Site personnel were given visual inspection tools and training before systematically examining fully processed endoscopes twice during a 2-month period. A risk assessment protocol was used to determine whether endoscopes required recleaning, repair, or other action. Findings were documented using log sheets, photographs, and videotapes.

RESULTS

Visible damage and residue or debris were observed in 100% of 25 endoscopes at both assessments, and 76% required repair. Defects at baseline included scratches (88%); channel shredding or peeling (80%); adhesive band disintegration (80%); residual soil or debris (white 84%; black 68%; brown 40%; yellow/green 36%; and orange/red 8%); retained fluid (52%); and dents (40%). Findings were similar at follow-up.

DISCUSSION/CONCLUSIONS

Visual inspection with magnification and borescopes identified actionable defects that could interfere with processing effectiveness in 100% of endoscopes. Infection preventionists have a critical role to play in supporting processing personnel now that standards, guidelines, and manufacturer instructions recommend enhanced visual inspection of every endoscope, every time.

Infection control in the bronchoscopy suite: effective reprocessing and disinfection of reusable bronchoscopes

PURPOSE OF REVIEW

With advancements in technology, flexible bronchoscopes have become thinner in diameter and in need of more thorough reprocessing to prevent infection transmission than ever before. Many experienced bronchoscopists are not aware of the critical steps involved in effective bronchoscope reprocessing and we hope to bridge this gap by describing this process in detail.

RECENT FINDINGS

Bronchoscope reprocessing includes several distinct steps (precleaning, leak testing, manual cleaning, visual inspection, terminal reprocessing, rinsing and drying). Each step is comprehensive and needs to be carried out systematically by trained personnel. Failure of any step can lead to serious downstream events such as outbreaks and pseudo-outbreaks. Some experts now recommend sterilization when feasible, although high-level disinfection remains the minimum standard. We also will review some literature on the utility of borescopes, automated endoscope reprocessors and disposable bronchoscopes.

SUMMARY

Our article will focus on the most recent recommendations for effective reprocessing and disinfection of reusable bronchoscopes.

The Cost of Flexible Bronchoscopes: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE

Until 2009, only reusable bronchoscopes were marketed, but the introduction and widespread adoption of single-use flexible bronchoscopes (SFBs) as an emerging technology has since accelerated. Several studies have described the costs of reusable flexible bronchoscopes (RFBs) and SFBs. This meta-analysis aimed to compile the current published evidence to analyse the cost of different scenarios using RFBs and SFBs.

METHODS

All published literature describing the cost of RFBs or SFBs was identified by searching PubMed, Embase and Google Scholar, limited to those between 1 January, 2009 and 6 November, 2020. Included studies should report the total cost of RFBs. Continuous data were extracted for relevant outcomes and analysed using RStudio^® 4.0.3 as the standardised mean difference and standard error of the mean in a mixed-effects model. Risk of bias was assessed based on the reporting quality.

RESULTS

In the systematic literature review, 342 studies were initially identified, and 11 were included in the final analysis. The mean RFB procedure cost was $266 (standard error of the mean: 34), including capital investments, repairs and reprocessing costs of $91, $92 and $83, respectively. The mean SFB procedure cost was $289 (standard error of the mean: 10). The incremental cost was $23 (standard error of the mean: 33) and was not significant (p = 0.46). Because of the economy of scale, RFB is more likely to be cost minimising compared with SFB when performing 306 or 39 procedures per site or RFB, respectively.

CONCLUSIONS

In this study, we found no significant difference in the cost of use between RFBs and SFBs and a high risk of bias.

Adoption of Improved Reprocessing Decreased Microbiological Non-Compliance for Bronchoscopes

BACKGROUND

In the past few decades, the inadequate reprocessing of bronchoscopes has been associated with several serious outbreaks caused by multidrug-resistant microorganisms. In this study we evaluated the improvement in the quality of reprocessing in a Bronchoscopy Unit (BU), after the introduction of a new procedure.

METHODS

In 2019, observational and clinical audits were conducted in the BU. After the introduction of an improved procedure in 2020, a microbiological surveillance plan was implemented in 2021.

RESULTS

In 2019, 13 of 22 bronchoscopes (59%) resulted as non-compliant, 18% as high concern organisms (HCO) and 36.4% as high microbial count (≥100 CFU/all channels) and HCO. The most frequent microorganisms were Staphylococcus aureus (38.5%) and NDM-producing Klebsiella pneumoniae (15.4%). The bronchoscopes were stored inside their transport cases, which in some cases were found to be contaminated by the same strains isolated on the bronchoscopes (Enterobacter gergoviae and Vibrio alginolyticus). In 2021, all 31 bronchoscopes were sampled at least three times and 13/99 (13.1%) resulted as non-compliant, mostly K. pneumoniae (4.04%). Contamination level increases weakly in bronchoscopes in use for more than 14 years (R = 0.32).

CONCLUSIONS

The adoption of an improved reprocessing procedure decreased the non-compliance of bronchoscopes, increasing the quality of the process and patient safety.

Evaluation of a new developed disposable and portable bronchoscopy system

Background

Bronchoscopy is critical in the treatment of patients with coronavirus disease (COVID-19), and its use is associated with the challenges of stringent sterilization and virus transmission risk. We developed a disposable and portable bronchoscope (YunSendo-R) and compared its safety and function with those of current reusable and single-use bronchoscopes using an animal model.

Methods

We compared the YunSendo-R system with a commercially available reusable bronchoscope (Olympus, BF-H290) and single-use bronchoscope (Ambu, Ambu® aScope3™). Eight physicians used the three types of bronchoscopes to operate on Guangxi Bama mini pigs. Each operator performed bronchoscopy and completed a 10-point Likert scale questionnaire for evaluating visual ability and manoeuvrability. Operation time and scores were collected.

Results

Operation time had no significant differences among the three bronchoscopes. In visual ability, the YunSendo-R bronchoscope showed superior performance to the Ambu bronchoscope in image clarity, colour contrast, and illumination (P < 0.05) and no significant difference in performance compared with the Olympus bronchoscope (P > 0.05). The YunSendo-R bronchoscope had similar manoeuvrability to the Olympus bronchoscope and better scope tip flexibility than the Ambu bronchoscope (P > 0.05). No relevant complications were reported.

Conclusion

We have developed a new bronchoscopy system with the advantages of disposability and portability, which was effective and safe in an animal model. It has better visual ability than the Ambu bronchoscope and similar visual ability and manoeuvrability to the Olympus bronchoscope. The YunSendo-R bronchoscope is a promising device for clinical practice, especially in reusable-endoscope-transmitted infectious diseases such as COVID-19.

Percutaneous dilatational tracheostomy with single use bronchoscopes versus reusable bronchoscopes – a prospective randomized trial (TraSUB)

Background

Apart from conventional reusable bronchoscopes, single-use bronchoscopes (SUB) were recently introduced. Data suggest that SUB might prevent from the risk of cross contamination (i.e. multiresistant pathogens, SARS CoV-2) and save costs. We aimed to investigate visualization, ventilation, handling characteristics, changes in patients’ gas exchange, and costs associated with both types of bronchoscopes during percutaneous dilatational tracheostomy (PDT).

Methods

In this prospective, randomized, noninferiority study, 46 patients undergoing PDT were randomized 1:1 to PDT with SUB (Ambu aScope) or reusable bronchoscopes (CONV, Olympus BF-P60). Visualization of tracheal structures rated on 4-point Likert scales was the primary end-point. Furthermore, quality of ventilation, device handling characteristics, changes in the patients’ gas exchange, pH values, and costs were assessed.

Results

Noninferiority for visualization (the primary endpoint) was demonstrated for the SUB group. Mean visualization scores (lower values better) were 4.1 (95% confidence intervals: 3.9;4.3) for SUB vs. 4.1 (4.0;4.2) for CONV. Noninferiority of ventilation (estimated by minute volume and SpO₂) during the procedure could be shown as well. Mean score was 2.6 (2.0;3.1) for SUB vs. 2.4 (2.1;2.7) for CONV (lower values better). No significant differences regarding handling (SUB: 1.2 (1.0;1.4), CONV: 1.3 (1.1;1.6)), blood gas analyses and respiratory variables were found. Cost analysis in our institution revealed 93 € per conventional bronchoscopy versus 232.50 € with SUB, not considering an estimate for possible infection due to cross-contamination with the reusable device.

Conclusion

In our study, visualization and overall performance of the SUB during PDT were noninferior to reusable bronchoscopes. Therefore, PDT with SUB is feasible and should be considered if favored by individual institution’s cost analysis.

Trial registration.

ClinicalTrials.gov, NCT03952247. Submitted for registration on 28/04/2019 and first posted on 16/05/2019.

Single-Use and Reusable Flexible Bronchoscopes in Pulmonary and Critical Care Medicine

Flexible bronchoscopy plays a critical role in both diagnostic and therapeutic management of a variety of pulmonary disorders in the bronchoscopy suite and the intensive care unit. In the set-ting of the ongoing viral pandemic, single-use flexible bronchoscopes (SUFB) have garnered attention as various professional pulmonary societies have released guidelines regarding uses for SUFB given the concern for risk of viral transmission when using reusable flexible bronchoscopes (RFB). In addition to offering sterility, SUFBs are portable, easily accessible, and may be more cost-effective than RFB when considering the potential costs of treating bronchoscopy-related infections. Furthermore, since SUFBs are one time use, they do not require reprocessing after use, and therefore may translate to reduced cleaning and storage costs. Despite these advantages, RFBs are still routinely used to perform advanced diagnostic and therapeutic bronchoscopic procedures given the need for optimal maneuverability, handling, angle of deflection, image quality, and larger channel size for passing of ancillary instruments. Here, we review the published evidence on the applications of single-use and reusable bronchoscopes in bronchoscopy suites and intensive care units. Specifically, we will discuss the advantages and disadvantages of these devices as pertinent to fundamental, advanced, and therapeutic bronchoscopic interventions.

Cost-comparison study of reusable and disposable rhinolaryngoscopes in a large English teaching hospital

OBJECTIVE

This study aimed to compare the cost per use of video-rhinolaryngoscopy using reusable and disposable devices in a tertiary referral centre.

METHODS

A cost-comparison study was performed that utilised retrospective cost data and prospective utilisation data to compare the total costs of using reusable video-rhinolaryngoscopes versus a single-use alternative.

RESULTS

It was estimated that 4776 and 1821 procedures were performed annually with reusable and disposable video-rhinolaryngoscopes, respectively. The cost per use was £66.61 for reusable devices versus £150.00 for disposable devices. The break-even point (i.e. when cost per use was equal, occurred at 1374 procedures per year). Thereafter, it was cheaper to use reusable devices.

CONCLUSION

Disposable rhinolaryngoscopes may present a cheaper solution to services with low rates of rhinolaryngoscope utilisation. However, for larger services considering replacement of their reusable rhinolaryngoscopes with disposable units, it is likely that the recurring costs will be prohibitive in the medium to long term.

Both microbiological surveillance and audit of procedures improve reprocessing of flexible bronchoscopes and patient safety

BACKGROUND

Microbiological surveillance of bronchoscopes and automatic endoscope reprocessors (AERs)/washer disinfectors as a quality control measure is controversial. Experts also are divided on the infection risks associated with bronchoscopic procedures.

OBJECTIVE

We evaluated the impact of routine microbiological surveillance and audits of cleaning/disinfection practices on contamination rates of reprocessed bronchoscopes.

DESIGN

Audits were conducted of reprocessing procedures and microbiological surveillance on all flexible bronchoscopes used from January 2007 to June 2020 at a teaching hospital in France. Contamination rates per year were calculated and analyzed using a Poisson regression model. The risk factors for microbiological contamination were analyzed using a multivariable logistical regression model.

RESULTS

In total, 478 microbiological tests were conducted on 91 different bronchoscopes and 57 on AERs. The rate of bronchoscope contamination significantly decreased between 2007 and 2020, varying from 30.2 to 0% (P < .0001). Multivariate analysis confirmed that retesting after a previous contaminated test was significantly associated with higher risk of bronchoscope contamination (OR, 2.58; P = .015). This finding was explained by the persistence of microorganisms in bronchoscopes despite repeated disinfections. However, the risk of persistent contamination was not associated with the age of the bronchoscope.

CONCLUSIONS

Our results confirm that bronchoscopes can remain contaminated despite repeated reprocessing. Routine microbial testing of bronchoscopes for quality assurance and audit of decontamination and disinfection procedures can improve the reprocessing of bronchoscopes and minimize the rate of persistent contamination.

Sans Standardization: Effective Endoscope Reprocessing

Bronchoscopy is a commonly performed procedure within thoracic and critical care medicine. Modern bronchoscopes are technologically advanced tools made of fragile electronic components. Their design is catered to allow maximum maneuverability within the semi-rigid tracheobronchial tree. Effective cleaning and reprocessing of these tools can be a challenge. Although highly functional, the design poses several challenges when it comes to reprocessing. It is a very important step, and lapses in the procedure have been tied to nosocomial infections. The process lacks universal standardization; several organizations have developed their own recommendations. Data have shown that key stakeholders are not fully versed in the essentials of endoscope reprocessing. A significant knowledge gap exists between those performing bronchoscopy and those who are stewards of effective endoscope reprocessing. To service as a resource for bronchoscopists, this study summarizes the steps of effective reprocessing, details the important elements within a health-care facility that houses this process, and reviews some of the current data regarding the use of disposable endoscopes.

Can single-use bronchoscopes help prevent nosocomial COVID-19 infections?

Introduction: The reduction of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission has been achieved through numerous public health initiatives worldwide. In the hospital environment, certain high-risk procedures have the potential to cause transmission of the virus to health-care workers and nosocomial transmission to patients through different mechanisms including the generation of aerosols and fomite formation via contamination of medical devices.Areas covered: Aerosol-generating procedures such as bronchoscopy are considered high risk for SARS-CoV-2 transmission. As a result, single-use devices should be used where possible and changing to single-use flexible bronchoscopes has been advised by respiratory societies internationally. In this paper, we outline the rationale for this advice and have analyzed the evidence relating to the reduction in SARS-CoV-2 transmission arising from a switch to these single-use devices and the potential impact that this switch may have on the quality of pulmonology services.Expert opinion: In this paper, we outline the rationale for this advice and have analyzed the evidence relating to the reduction in SARS-CoV-2 transmission arising from a switch to these single-use devices and the potential impact that this switch may have on the quality of pulmonology services.

Bronchoscopist's perception of the quality of the single-use bronchoscope (Ambu aScope4™) in selected bronchoscopies: a multicenter study in 21 Spanish pulmonology services

BACKGROUND

The disposable bronchoscope is an excellent alternative to face the problem of SARS-CoV-2 and other cross infections, but the bronchoscopist's perception of its quality has not been evaluated.

METHODS

To evaluate the quality of the Ambu-aScope4 disposable bronchoscope, we carried out a cross-sectional study in 21 Spanish pulmonology services. We use a standardized questionnaire completed by the bronchoscopists at the end of each bronchoscopy. The variables were described with absolute and relative frequencies, measures of central tendency and dispersion depending on their nature. The existence of learning curves was evaluated by CUSUM analysis.

RESULTS

The most frequent indications in 300 included bronchoscopies was bronchial aspiration in 69.3% and the median duration of these was 9.1 min. The route of entry was nasal in 47.2% and oral in 34.1%. The average score for ease of use, image, and aspiration quality was 80/100. All the planned techniques were performed in 94.9% and the bronchoscopist was satisfied in 96.6% of the bronchoscopies. They highlighted the portability and immediacy of the aScope4TM to start the procedure in 99.3%, the possibility of taking and storing images in 99.3%. The CUSUM analysis showed average scores > 70/100 from the first procedure and from the 9th procedure more than 80% of the scores exceeded the 80/100 score.

CONCLUSIONS

The aScope4™ scored well for ease of use, imaging, and aspiration. We found a learning curve with excellent scores from the 9th procedure. Bronchoscopists highlighted its portability, immediacy of use and the possibility of taking and storing images.

Duodenoscope-associated infection prevention: A call for evidence-based decision making

Background  Recent outbreaks of duodenoscope-associated multidrug-resistant organisms (MDROs) have brought attention to the infection risk from procedures performed with duodenoscopes. Prior to these MDRO outbreaks, procedures with duodenoscopes were considered safe and low risk for exogenous infection transmission, provided they were performed in strict accordance with manufacturer instructions for use and multisociety reprocessing guidelines. The attention and efforts of the scientific community, regulatory agencies, and the device industry have deepened our understanding of factors responsible for suboptimal outcomes. These include instrument design, reprocessing practices, and surveillance strategies for detecting patient and instrument colonization. Various investigations have made it clear that current reprocessing methods fail to consistently deliver a pathogen-free instrument. The magnitude of infection transmission has been underreported due to several factors. These include the types of organisms responsible for infection, clinical signs presenting in sites distant from ERCP inoculation, and long latency from the time of acquisition to infection. Healthcare providers remain hampered by the ill-defined infectious risk innate to the current instrument design, contradictory information and guidance, and limited evidence-based interventions or reprocessing modifications that reduce risk. Therefore, the objectives of this narrative review included identifying outbreaks described in the peer-reviewed literature and comparing the findings with infections reported elsewhere. Search strategies included accessing peer-reviewed articles, governmental databases, abstracts for scientific conferences, and media reports describing outbreaks. This review summarizes current knowledge, highlights gaps in traditional sources of evidence, and explores opportunities to improve our understanding of actual risk and evidence-based approaches to mitigate risk.

Research: Fluorescence Microscopy-Based Protocol for Detecting Residual Bacteria on Medical Devices

Standard methods are needed to reliably and efficiently assess bacterial contamination of processed medical devices. This article demonstrates a standard operating procedure (SOP) for fluorescence microscopy-based detection of residual bacteria on medical devices (BAC-VIS). BAC-VIS uses a 4',6-diamidino-2-phenylindole (DAPI) stain with fluorescent microscopy to quickly and cost-effectively detect bacterial contamination of processed medical device parts. The BAC-VIS protocol was optimized and achieved greater than 80% staining efficiency and a signal-to-noise ratio of more than 20 using four representative organisms. The SOP was first validated for use on a buildup biofilm model, accessory channels of contaminated clinically used devices, and inoculated endoscope end caps and O-rings. The buildup biofilm model was used to evaluate BAC-VIS after repeated treatment of adherent bacteria with three common high-level disinfectants: glutaraldehyde, ortho-phthalaldehyde, and peracetic acid. Next, BAC-VIS was used to assess clinically used endoscope parts that cultured positive for Gram-negative bacteria. DAPI-stained cells were found on all culture-positive devices, especially in grooves and imperfections on the surface. Finally, BAC-VIS was used to detect bacteria on inoculated endoscope device components. The results showed potential for BAC-VIS to be a valuable tool for industry and academic/medical researchers for investigations of contaminated medical devices. Results obtained using BAC-VIS can increase understanding of the role of design in cleanability, wear, and prevention of contamination and may lead to improvements in materials and design that could make processed endoscope use safer for patients. Of note, this protocol is not for detecting bacteria on scopes or scope parts that will be put back into clinical use.

Single-Use (Disposable) Flexible Bronchoscopes: The Future of Bronchoscopy?

The coronavirus disease (COVID-19) pandemic has highlighted the importance of reducing occupational exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The reprocessing procedure for reusable flexible bronchoscopes (RFBs) involves multiple episodes of handling of equipment that has been used during an aerosol-generating procedure and thus is a potential source of transmission. Single-use flexible bronchoscopes (SUFBs) eliminate this source. Additionally, RFBs pose a risk of nosocomial infection transmission between patients with the identification of human proteins, deoxyribonucleic acid (DNA) and pathogenic organisms on fully reprocessed bronchoscopes despite full adherence to the guidelines. Bronchoscopy units have been hugely impacted by the pandemic with restructuring of pre- and post-operative areas, altered patient protocols and the reassessment of air exchange and cleaning procedures. SUFBs can be incorporated into these protocols as a means of improving occupational safety. Most studies on the efficacy of SUFBs have occurred in an anaesthetic setting so it remains to be seen whether they will perform to an acceptable standard in complex respiratory procedures such as transbronchial biopsies and cryotherapy. Here, we outline their potential uses in a respiratory setting, both during and after the current pandemic.

Single-Use (Disposable) Flexible Bronchoscopes: The Future of Bronchoscopy?

The coronavirus disease (COVID-19) pandemic has highlighted the importance of reducing occupational exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The reprocessing procedure for reusable flexible bronchoscopes (RFBs) involves multiple episodes of handling of equipment that has been used during an aerosol-generating procedure and thus is a potential source of transmission. Single-use flexible bronchoscopes (SUFBs) eliminate this source. Additionally, RFBs pose a risk of nosocomial infection transmission between patients with the identification of human proteins, deoxyribonucleic acid (DNA) and pathogenic organisms on fully reprocessed bronchoscopes despite full adherence to the guidelines. Bronchoscopy units have been hugely impacted by the pandemic with restructuring of pre- and post-operative areas, altered patient protocols and the reassessment of air exchange and cleaning procedures. SUFBs can be incorporated into these protocols as a means of improving occupational safety. Most studies on the efficacy of SUFBs have occurred in an anaesthetic setting so it remains to be seen whether they will perform to an acceptable standard in complex respiratory procedures such as transbronchial biopsies and cryotherapy. Here, we outline their potential uses in a respiratory setting, both during and after the current pandemic.

The single-use rhinolaryngoscope: an evaluation and cost comparison

BACKGROUND

This study investigated whether the single-use rhinolaryngoscope is clinically and economically comparable to the conventional reusable rhinolaryngoscope within a tertiary otolaryngology centre in the UK.

METHODS

A non-blinded, prospective and single-arm evaluation was carried out over a 5-day period, in which micro-costing was used to compare single-use rhinolaryngoscopes with reusable rhinolaryngoscopes.

RESULTS

Overall, 68 per cent of the investigators perceived the single-use rhinolaryngoscope to be 'good' or 'very good', while 85 per cent believed the single-use rhinolaryngoscope could replace the reusable rhinolaryngoscope (n = 59). The incremental costs of reusable rhinolaryngoscope eyepieces and videoscopes in the out-patient clinic, when compared to single-use rhinolaryngoscopes, were £30 and £11, respectively. The incremental costs of reusable rhinolaryngoscope eyepieces and videoscopes in the acute surgical assessment unit, when compared to single-use rhinolaryngoscopes, were -£4 and -£73, respectively.

CONCLUSION

The single-use rhinolaryngoscope provides a clinically comparable, and potentially cost-minimising, alternative to the reusable rhinolaryngoscope for use in the acute surgical assessment unit of our hospital.

The grasper-integrated disposable flexible cystoscope is comparable to the reusable, flexible cystoscope for the detection of bladder cancer

Flexible cystoscopy under local anaesthesia is standard for the surveillance of bladder cancer. Frequently, several reusable cystoscopes fail to reprocess. With the new grasper incorporated single-use cystoscope for retrieval of ureteric stents, we explored the feasibility of using it off-label for diagnosis and the detection of bladder cancer. Consecutive diagnostic flexible cystoscopies between Mar 2016 and Nov 2018 were reviewed comparing the reusable versus the disposable cystoscopes. A total of 390 patients underwent 1211 cystoscopies. Median age was 61.5 years (SD 14.2, 18.8–91.4), males 331 (84.9%) and females 59 (15.1%). Indication for cystoscopy was prior malignancy in 1183 procedures (97.7%), haematuria 19 (1.6%) or bladder mass 7 (0.6%). There were 608 reusable and 603 disposable cystoscopies. There was no significant difference between groups at baseline in age, sex, BMI, smoking status, or prior tumor risk category. There was no significant difference in positive findings (123/608, 20.2% vs 111/603, 18.4%, p = 0.425) or cancer detection rates (95/608, 15.6% vs 88/603, 14.4%, p 0.574) among the two groups, respectively. We conclude that the disposable grasper integrated cystoscope is comparable to reusable cystoscope in the detection of bladder cancer.

Rate and impact of duodenoscope contamination: A systematic review and meta-analysis

BACKGROUND

Multiple infection outbreaks have been linked to contaminated duodenoscopes worldwide. However, the contamination rate of patient-ready duodenoscopes varies highly amongst published studies testing this subject. We aimed to estimate the contamination rate of reprocessed patient-ready duodenoscopes for endoscopic retrograde cholangio-pancreatography (ERCP) based on currently available data.

METHODS

We searched the PubMed and Embase databases from January 1, 2010 until March 10, 2020, for citations investigating contamination rates of reprocessed patient-ready duodenoscopes. Studies not assessing other types of endoscopes than duodenoscopes were excluded from the analysis. Study eligibility and data extraction was evaluated by three reviewers independently. A random-effects model (REM) based on the proportion distribution was used to calculate the pooled total contamination rate of reprocessed patient-ready duodenoscopes. Subgroup analyses were carried out to assess contamination rates when using different reprocessing methods by comparing single high-level disinfection (HLD) with double HLD and ethylene oxide (EtO) gas sterilization. Additionally, we investigated the contamination rate between studies conducted following an outbreak compared to non-outbreak-initiated studies.

FINDINGS

We identified 15 studies that fulfilled the inclusion, which included 925 contaminated duodenoscopes from 13,112 samples. The calculated total weighted contamination rate was 15.25% ± 0.018 (95% confidence interval [Cl]: 11.74% - 18.75%). The contamination rate after only using HLD was 16.14% ± 0.019 (95% Cl: 12.43% - 19.85%) and after using either dHLD or EtO the contamination rate decreased to 9.20% ± 0.025 (95% Cl: 4.30% - 14.10%). Studies conducted following an outbreak (n=4) showed a 5.72% ± 0.034 (95% Cl: 0.00% - 12.43%) contamination rate, and non-outbreak-initiated studies (n=11) revealed a contamination rate of 21.50% ± 0.031 (95% Cl: 15.35% - 27.64%).

INTERPRETATION

This is the first meta-analysis to estimate the contamination rate of patient-ready duodenoscopes used for ERCP. Based on the available literature, our analysis demonstrates that there is a 15.25% contamination rate of reprocessed patient-ready duodenoscopes. Additionally, the analysis indicates that dHLD and EtO reprocessing methods are superior to single HLD but still not efficient in regards to cleaning the duodenoscopes properly. Furthermore, studies conducted following an outbreak did not entail a higher contamination rate compared to non-outbreak-initiated studies.

FUNDING

The authors received no financial support for the research, authorship, and/or publication of this article.

SEPAR and AEER consensus recommendations on the Use of Bronchoscopy and Airway Sampling in Patients with Suspected or Confirmed COVID-19 Infection

Este documento de consenso está elaborado por el área de Técnicas y Trasplante y el área de Enfermería de la Sociedad Española de Neumología y Cirugía Torácica, así como por la Asociación Española de Endoscopia Respiratoria, con el objetivo de proporcionar conocimientos para el uso efectivo y seguro de la broncoscopia en pacientes con sospecha o con confirmación de la infección por COVID-19. Es prioritario proporcionar la mayor seguridad a nuestros pacientes, a los sanitarios que los atienden y a la comunidad en general.

En este momento de pandemia, la información de la que disponemos acerca del uso de la broncoscopia en este tipo de pacientes se basa en la experiencia de otros centros y países, y las publicaciones científicas son escasas. El objetivo de este documento es recoger esas experiencias y, en base a las recomendaciones de los organismos oficiales, ofrecer un documento de ayuda para la práctica clínica diaria.

Challenges in achieving effective high-level disinfection in endoscope reprocessing

Endoscope reprocessing is often ineffective, and microbes frequently remain on endoscopes after the use of high-level disinfectants (HLDs). Several factors impact reprocessing effectiveness, including non-adherence to guidelines, use of damaged endoscopes, use of insoluble products during endoscopy, insufficient cleaning, contaminated rinse water, and inadequate drying before storage. Our team suspected that issues with HLD chemistries and monitoring could also contribute to reprocessing failures. We conducted a mixed-methods analysis of published literature, our interviews with frontline personnel, and evidence from our previous studies. The evidence showed that reusable HLDs commonly failed tests for minimum effective concentration (MEC) before their maximum usage periods. MEC tests also detected failures associated with single-use HLDs that did not fully deploy. These failures were due to product issues, process complexities, and personnel non-adherence with guidelines and manufacturer instructions. HLDs will likely continue to be used for the foreseeable future. More research is needed to assess real-world practice patterns related to the high-level disinfection step and MEC testing and to establish more realistic usage periods for reusable HLD chemistries. Manufacturers and researchers should evaluate the ability of technological solutions and engineered safeguards to overcome human error. Recognition of the need for quality improvement is growing, and infection preventionists should take action to build on this momentum and collaborate with manufacturers, endoscopists, and reprocessing personnel to improve the effectiveness of high-level disinfection.

Recovery of Curvularia mold from a duodenoscope after reprocessing in accordance with the manufacturer's cleaning protocol

In 2018, the Food and Drug Administration/Centers for Disease Control and Prevention revised protocols for surveillance sampling and cultures of duodenoscopes. We describe the recovery of the mold Curvularia from a duodenoscope processed according to the manufacturer's instructions using this revised sampling process. To our knowledge, this is the first time a mold has been recovered from a duodenoscope after following the Food and Drug Administration/Centers for Disease Control and Prevention protocol. This suggests that manufacturer's recommendation for scope reprocessing may be insufficient to adequately remove mold from these scopes.

Bronchoscope-related Pseudomonas aeruginosa pseudo-outbreak attributed to contaminated rinse water

BACKGROUND

Increased percentage of Pseudomonas aeruginosa from bronchoalveolar lavage fluid of patients in June 2016 was observed. P aeruginosa were also obtained from flexible bronchoscope and rinse water in the microbiological surveillance in June 2016.

METHODS

Reprocessing procedure of bronchoscope was assessed, and environmental samples were collected. P aeruginosa isolates recovered from bronchoalveolar lavage fluid of patients between May and September 2016 and environment were characterized using multilocus sequence typing and pulsed-field gel electrophoresis.

RESULTS

A novel multilocus sequence type (ST) of P aeruginosa was defined as ST 2387. ST671 and ST 2387 were both cultured from bronchoscopes and connecting tube in manual reprocessing cleaning equipment. One strain from a patient was indistinguishable from the clones obtained from the bronchoscope and connecting tube revealed by pulsed-field gel electrophoresis. Two strains from 2 patients from the burn intensive care unit were identical, and highly related to 2 other strains from the burn intensive care unit. The persistence of P aeruginosa in bronchoscopes, connecting tubes, and final rinse water was terminated by replacement of the connecting tube.

CONCLUSIONS

We report a pseudo-outbreak of P aeruginosa associated with bronchoscope, for which connecting tube was the hidden reservoir for contaminating bronchoscopes. This highlights that effective measures are needed to control the bacterial load in final rinsing water to protect reusable equipment from contamination in reprocessing and cleaning.

A systematic review and cost effectiveness analysis of reusable vs. single-use flexible bronchoscopes

The cost effectiveness of reusable vs. single‐use flexible bronchoscopy in the peri‐operative setting has yet to be determined. We therefore aimed to determine this and hypothesised that single‐use flexible bronchoscopes are cost effective compared with reusable flexible bronchoscopes. We conducted a systematic review of the literature, seeking all reports of cross‐contamination or infection following reusable bronchoscope use in any clinical setting. We calculated the incidence of these outcomes and then determined the cost per patient of treating clinical consequences of bronchoscope‐induced infection. We also performed a micro‐costing analysis to quantify the economics of reusable flexible bronchoscopes in the peri‐operative setting from a high‐throughput tertiary centre. This produced an accurate estimate of the cost per use of reusable flexible bronchoscopes. We then performed a cost effectiveness analysis, combining the data obtained from the systematic review and micro‐costing analysis. We included 16 studies, with a reported incidence of cross‐contamination or infection of 2.8%. In the micro‐costing analysis, the total cost per use of a reusable flexible bronchoscope was calculated to be £249 sterling. The cost per use of a single‐use flexible bronchoscope was £220 sterling. The cost effectiveness analysis demonstrated that reusable flexible bronchoscopes have a cost per patient use of £511 sterling due to the costs of treatment of infection. The findings from this study suggest benefits from the use of single‐use flexible bronchoscopes in terms of cost effectiveness, cross‐contamination and resource utilisation.

A Blueprint for Success: Design and Implementation of an Ideal Bronchoscopy Suite

Bronchoscopy is essential to the practice of pulmonary medicine. It is an important diagnostic and therapeutic tool for many disease processes. Bronchoscopy can be performed in a variety of clinical settings, from the bedside to an operating room. Although bronchoscopy has been practiced for more than a century, consensus recommendations from stakeholders have yet to be developed for the planning, implementation, and construction of a bronchoscopy suite. A wide range of procedures can be performed via bronchoscopy; therefore, the required tools and the procedure area must be aligned with the needs of the facility. Designing a bronchoscopy suite is by no means a "one size fits all" process. We present an overview of critical features to be considered in the planning for an ideal bronchoscopy suite. We use the term "ideal" because it represents a subjective conception of what is perfect and does not convey a rigid, universal blueprint.

Medical instrument reprocessing: current issues with cleaning and cleaning monitoring

The complexity of medical devices has increased over the past 10 years, and outbreaks of infections due to contaminated devices have focused attention on the need to adequately clean medical devices in order to ensure the adequacy of disinfection and sterilization. There has been a paradigm shift in reprocessing of medical devices, with increased emphasis on a quality management systems approach that requires validated cleaning instructions from manufacturers and ongoing monitoring by reprocessing personnel to ensure adequacy of cleaning. This article reviews the current issues related to medical device reprocessing and summarizes the approaches used for monitoring cleaning efficacy for surgical instruments and flexible endoscopes.